Form FSA-1118 PANDEMIC ASSISTANCE FOR TIMBER HARVESTERS AND HAULERS (P

Form Approved - OMB No. 0560-XXXX

OMB Expiration Date: XX/XX/2021

FSA-1118 U.S. DEPARTMENT OF AGRICULTURE

(proposal 19) Farm Service Agency

PANDEMIC ASSISTANCE FOR TIMBER

HARVESTERS AND HAULERS

(PATHH) PROGRAM APPLICATION

1. Recording State

     

2. Program Year

2020

3. Recording County

     

4. Application Number

     

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended). The authority for requesting the information identified on this form is 7 CFR Part 9, the CARES Act (Pub. L. 116-136), and 15 U.S.C. 714b and 714c.  The information will be used to determine eligibility for program benefits.  The information collected on this form may be disclosed to other Federal, State, and Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated).  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility for program benefits. Payments may be made under the program to which the form applies only to the extent permitted by applicable authorities.

Public Burden Statement (Paperwork Reduction Act):  Public reporting burden for this collection is estimated to average 15 minutes per response, including reviewing instructions, gathering and maintaining the data needed, completing (providing the information), and reviewing the collection of information. You are not required to respond to the collection, or USDA may not conduct or sponsor a collection of information unless it displays a valid OMB control number.  RETURN THIS COMPLETED FORM TO LOCAL USDA-FARM SERVICE AGENCY OFFICE.

PART A – TIMBER HARVESTER/HAULER AGREEMENT

The Department of Agriculture (USDA) will make PATHH payments to eligible timber hauling and harvesting businesses that meet the requirements of the program. The following information is needed in order for USDA to make a determination that the applicant is eligible to receive a PATHH payment. By submitting this application, and upon its approval by USDA, the applicant agrees:

1.	To comply with, and acknowledges the applicant is subject to, all provisions of PATHH as published in the Notice of Funds Availability published in the Federal Register, and all applicable rules and regulations.
2.	That the applicant meets the definition of a timber harvesting business or timber hauling business and 50 percent or more of the business’s gross revenue is derived from harvesting and/or hauling timber
3.	The applicant’s gross revenue between January 1, 2020 and December 1, 2020, declined 10% or more compared to gross revenue between January 1, 2019, and December 1, 2019. NOTE: The time periods are not full calendar years.
4.	To complete and submit the following forms applicable to the PATHH program: To comply with applicant eligibility and payment limitation provisions: AD-2047, Customer Data Worksheet, if applicable CCC-901, Member Information for Legal Entities, if applicable To comply with the provisions of the Food Security Act of 1985 that protect highly erodible land and wetlands: AD-1026, Highly Erodible Land Conservation (HELC) and Wetland Conservation (WC) Certification. NOTE: If the applicant does not have any farming interests, the applicant can certify to box 5a on the AD-1026. If the applicant is a Timber Hauler: IRS Form 2290, Heavy Highway Vehicle Use Tax Return, for logging vehicles for 2019 and 2020. NOTE: A copy of these forms must be submitted to the Farm Service Agency.
5.	To provide to USDA all information necessary to verify that the information provided on this form is accurate upon request, allow USDA representatives access to all documents and records of the applicant for the purpose of confirming the accuracy of the information provided, and submit all required documents within 60 days from the date the applicant submits this application. Failure of an individual, entity, or member of an entity to timely submit all information required may result in no payment or a reduced payment.

PART B – TIMBER HARVESTER/HAULER INFORMATION

5. Applicant Name, Address (City, State and Zip Code) and Phone Number (Include Area Code)

     

PART C – TIMBER HARVESTER/HAULER REVENUE

AGENCY USE ONLY

6.

Timber Business Type

7.

Principal Business Code

8.

2019 Gross Revenue

(Jan 1, 2019 –

Dec 1, 2019)

9.

2020 Gross Revenue

(Jan 1, 2020 –

Dec 1, 2020)

10.

Origination Date 2019

(Only complete if business operation originated after

January 1, 2019)

11.

Dissolution Date 2020

(Only complete if business operation dissolved prior to December 1, 2020)

12.

Agency Adjusted

2019 Revenue

13.

Agency Adjusted

2020 Revenue

14.

Agency Adjusted 2019 Origination Date

15.

Agency Adjusted 2020 Dissolution Date

Harvester (Only)

     

     

     

     

     

     

     

     

     

Hauler (Only)

     

     

     

     

     

     

     

     

     

Harvester & Hauler

     

     

     

     

     

     

     

     

     

Date Stamp

FSA-1118 (proposal 19) Page 2 of 2

PART D – TIMBER HARVESTER/HAULER CERTIFICATION
I certify the applicant identified in Part B Item 5 is an individual person that is a US Citizen or Resident Alien; or a legal entity, including corporation, LLC, LP, trust, estate, general partnership or joint venture, or similar type entity, comprised solely of persons who are U.S. Citizens or Resident Aliens; or is an Indian Tribe or Tribal organization, as defined in section 4 (b) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 5304). YES NO I certify that I have provided a copy of my IRS Form 2290, Heavy Highway Vehicle Use Tax Return, for logging vehicles for 2019 or that I hauled timber on tribal land in 2019 and am not required to complete IRS Form 2290. YES NO I certify that I have provided a copy of my IRS Form 2290, Heavy Highway Vehicle Use Tax Return, for logging vehicles for 2020 or that I hauled timber on tribal land in 2020 and am not required to complete IRS Form 2290. YES NO I certify by signing this application that the applicant is not a residential or commercial tree care business; landscape service; trucking business that does not transport trees or logs; timber brokers; and/or United States Federal, State, and local government. I hereby sign and acknowledge under penalty of perjury in accordance with 28 U.S.C. § 1746 and 18 U.S.C. § 1621 that the foregoing is true and correct.
16A. Signature (By)	16B. Title/Relationship of the Individual Signing in a Representative Capacity      			16C. Date (MM-DD-YYYY)      
PART E – COUNTY COMMITTEE (COC) DETERMINATION
17A. COC or Designee Signature		17B. Date (MM-DD-YYYY)      	18. Determination APPROVED DISAPPROVED

In accordance with Federal civil rights law and USDA civil rights regulations and policies, the USDA, its agencies, offices, and employees participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.